Examkin

Soru

Zorluk: ZorPhysiological Adaptation

A nurse is caring for a client who is receiving positive pressure mechanical ventilation for acute respiratory distress syndrome (ARDS). The client's most recent arterial blood gas (ABG) results are:

- pH: 7.28
- PaCO2: 58 mm Hg
- PaO2: 54 mm Hg
- HCO3-: 26 mEq/L

Over the last 15 minutes, the ventilator's high-pressure alarm has sounded, indicating the peak inspiratory pressure (PIP) has increased from 28 cm H2O to 48 cm H2O. The nurse auscultates the lungs and notes absent breath sounds on the right side. The client's current vital signs are BP 112/90 mm Hg (previously 124/72 mm Hg) and HR 118 beats/min. Which action is the priority for the nurse?

  1. A
    Document the narrowed pulse pressure as an expected physiological adaptation to positive pressure ventilation.
  2. B
    Administer prescribed intravenous sodium bicarbonate to correct the client's uncompensated metabolic acidosis.
  3. Prepare the equipment for an emergent needle thoracostomy and notify the healthcare provider.Cevap
  4. D
    Perform in-line endotracheal suctioning to clear a suspected mucus plug causing the high-pressure alarm.

Cevap

The priority action is to prepare the equipment for an emergent needle thoracostomy and notify the healthcare provider, as the client is exhibiting classic signs of a tension pneumothorax.
The client is exhibiting classic signs of a tension pneumothorax, a known complication of positive pressure ventilation (barotrauma) in ARDS. The sudden increase in peak inspiratory pressure (PIP), unilaterally absent breath sounds, and early signs of obstructive shock (tachycardia and a narrowed pulse pressure dropping from 52 mm Hg to 22 mm Hg) demand immediate life-saving intervention. Preparing the equipment for a needle thoracostomy or chest tube insertion is the highest priority to relieve the intrathoracic pressure and restore cardiac output.

Adım Adım Çözüm

1
Analyze the arterial blood gas (ABG) results.
The client has uncompensated respiratory acidosis (pH 7.28, PaCO2 58 mm Hg) and hypoxemia, which is common in ARDS but does not require sodium bicarbonate.
To rule out metabolic derangements as the primary cause of sudden deterioration.
2
Evaluate the ventilator alarms and respiratory assessment findings.
The sudden increase in peak inspiratory pressure (PIP) combined with unilaterally absent breath sounds indicates a collapsed lung (pneumothorax) rather than a simple mucus plug.
To identify the mechanical cause of the respiratory compromise.
3
Interpret the changing vital signs.
The transition from a BP of 124/72 to 112/90 mm Hg reveals a narrowed pulse pressure (22 mm Hg), which, along with tachycardia, is a subtle early sign of obstructive shock.
To recognize the physiological impact of the pneumothorax on cardiac output.
4
Determine the priority nursing intervention.
The findings confirm a developing tension pneumothorax, a life-threatening emergency requiring immediate needle decompression or chest tube insertion.
To prioritize actions that resolve the most immediate threat to the client's life.

Anahtar Kavram

Tension pneumothorax is a life-threatening complication of positive pressure ventilation (barotrauma) in ARDS, presenting with high peak inspiratory pressures, unilaterally absent breath sounds, and early signs of obstructive shock such as a narrowed pulse pressure.
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru